Article 1

Long bones giant cells tumors: Treatment by curretage and cavity filling cementation
N. Fraqueta, G. Faizonb, P. Rossetb, J.-M. Phillipeaua, c, D. Waasta and F. Gouina, , c,

Bone and Joint Unit, Hôtel Dieu teaching medical center, place A.-Ricordeau, 44093
a
Nantes cedex, France

bDepartment of Orthopaedics, hôpital Trousseau, Tours teaching medical center, Tours,
France
cEA3822, Inserm U957, Bone resorption physiopathology and primary bone tumors
therapy, research laboratory, Faculty of Medicine, Nantes University, Nantes, France
Accepted 22 July 2009.
Available online 19 September 2009.
Résultats cliniques et radiographiques à moyen terme du traitement par curetage
cimentation de 30 tumeurs à cellules géantes des os longs
Revue de Chirurgie Orthopédique et Traumatologique, Volume 95, Issue 6, October
2009, Pages 500-504,
Referred N. Fraquet, G. Faizon, P. Rosset, J.-M. Phillipeau, D. Waast, F. Gouin
to by:
PDF (501 K)
Summary
Objective
Giant cell tumors (GCT) of bone are benign tumors with local aggressiveness that most
of the time occur around the metaphyseal area of long bones, often in contact with the
articular cartilage. Their treatment remains controversial because of their high recurrence
rate. The authors report a retrospective series of 30 cases treated using curettage followed
by cementation. They suggest demonstrating the mechanical and functional benefit of this
technique, its benefit controlling the risk of recurrence, and of osteoarthritis potential.
Material and Methods
Between 1992 and 2005, 30 patients with GCT were treated using curettage and
cementation. Twenty-six of these tumors were present around the knee: 14 at the distal
femur and 12 at the proximal tibia. Preoperative radiological evaluation with standard X-
rays showed that the tumor measured a mean 71 × 45 mm, for a mean volume of 78 cm3.
Seventy-three percent of these GCT were in direct contact with the articular cartilage and
40% extended to the soft tissues as seen on the CAT scan and/or MRI. All patients were
treated with curettage and cementation, 16 additional internal fixation procedures were
performed. The mean follow-up of this series was 6 years and 4 months. All patients
continue to be monitored, with none lost to follow-up.
Results
In all our cases, nine recurrences (30%) were observed during the first 2 years. Six
patients were treated with a new curettage and cementation procedure and three
underwent a total knee arthroplasty. None of these lesions had recurred at the last follow-
up. The MSTS score, reflecting the function of the operated limb was a mean 93.33% (28
± 2/30). Standard radiological assessment showed a thin scalable border on four patients
and was normal for the all-total arthroplasty cases. Two cases of minor osteoarthritis
progression were noted (one less than 50% and a simple densification of subchondral
bone), requiring no specific treatment. Three complications were noted: one leg deep
venous thrombosis, one hematoma, and one deep infection without impacting the initial
treatment outcome over the long term.
Discussion
The curettage and cementation technique is usual practice in GCT treatment. Simple and
reproducible, this technique has a lower rate of complication than other treatment options
such as cryotherapy. It produces a lower rate of recurrence with the dual benefit of
excellent mechanical and functional qualities. Diagnosis of recurrence can be made
earlier because of the thin scalable border at the bone-cement interface. This technique
does not generally cause osteoarthritis, which was found in only two cases with no
evidence of the cement having a direct effect. The 30% recurrence rate observed in this
series shows that the benefit provided by the cement as an adjuvant preservative remains
modest.
Conclusion
The cement mechanical and cytotoxic properties as well as its innocuity and its ease of
handling make curettage and cementation one of the top-ranking GCT treatment options.
An even lower rate of recurrence may be obtained through development of additional
adjuvant treatments such as calcitonin and bisphosphonates.
Level of evidence
Level IV; Therapeutic study.
Keywords: Giant cell tumor; Cement; Curettage; PMMA
Article Outline
Introduction
Material and method
Results
Oncological results
Functional results
Radiographic results
Early complications
Discussion
Conclusion
References
Introduction
Giant cell tumors (GCT) of bone are benign tumors with local aggressiveness that most
frequently occur around the metaphyseal area of long bones, with frequent invasion of
subchondral bone, often in contact with joint cartilage. These are relatively frequent
tumors, accounting for 4–5% of bone tumors and 21% of benign tumors of the bone
according to Babinet [1] and Campanacci et al. [2]. Joint extension is exceptional.
Treatment of the periarticular tumors remains controversial because of the high
recurrence rate. Resection treats the tumor and prevents the risk of recurrence at the cost
of a less desirable functional result. Simple tumor curettage makes joint preservation
possible, with a better functional result, but the recurrence rate is higher: approximately
30–50% in the series reported by Babinet [1], Campanacci et al. [2], and Sung et al. [3].
This is why various adjuvant measures have been taken: intraoperative use of phenol [1],
cryotherapy by Malawer et al. [4] and Marcove et al. [5], combined with cementation
with acrylic cement [1].
According to Turcotte et al. [6], the curettage and cementation technique with acrylic
cement has the advantages of preservation of dynamic stability, thus allowing rapid
loading, early detection of recurrence with radiological observation of lysis at the
cement–bone interface, as well as the toxic properties of the methylmethacrylate
monomer and the necrotic effect of the heat given off during polymerization on the tumor
cells. It can also be used at the onset of pathological fracture. Nevertheless, the contact of
the cement with cartilage can damage the cartilage, possibly generating osteoarthrosis,
which has been studied by Vult Von Steyern et al. [7]. Thus, the problem of recurrence is
raised.
We have studied the results of this method on the recurrence rate and the iatrogenic
osteoarthritis rate. The series presented includes 30 patients with tumors located in the
knee (26 cases), the lower tibia (one case), the upper humerus (one case), the wrist (one
case), and the talus (one case).
Material and method
Between 1992 and 2005, 30 patients (12 females and 18 males), with a mean age of 36
years (range, 19–58), with GCT of the long bones were treated using the curettage and
cementation technique. Tumor type diagnosis was histological based on surgical biopsies
taken before any therapeutic act in all cases. All patients who had been operated on for a
benign giant cell tumor confirmed histologically with this method were included
retrospectively in the study. No diagnosis was made on extemporaneous anatomical-
pathological data.
Since histological grading of the benign GCT has not proven to have a prognostic or
therapeutic value and is no longer used, it was not taken into account [6].
In 14 cases (46.66%), the tumor was located in the lower femur, in 12 cases (40%) at the
upper tibia, in one case at the tibia, in one case at the upper humerus, in one case in the
wrist, and in one case in the talus.
The preoperative plain AP and lateral radiological analysis studied the following
parameters:
• tumor size: with a mean 71 × 48-mm AP dimension and 71 × 43-mm lateral dimension
(range, 23–150 mm);
• ratio of the greatest tumor/bone diameter at the same horizontal level. This ratio was a
mean 68% (range, 50%–93%) anteroposteriorly and 75% (range, 50%–97%) laterally.
All the tumors studied therefore involved more than 50% of the diameter of the bone
involved;
• mean volume calculated using the following formula: 0.5 × D × d2. This calculation was
valid considering that GCT are roughly ellipsoid and regular in shape. This gave a mean
tumor volume of 78 cm3 (range, 36–203 cm3);
• tumor position in relation to the cartilage: 22 tumors were in direct contact with the
joint cartilage (73%). This distance was evaluated on plain AP and lateral X-rays.
The preoperative CT or MRI studies showed extension to the soft tissues in 12 cases
(40%) (Fig. 1).
Full-size image (31K)
Figure 1. Preoperative X-ray.

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The indication for curettage and cementation surgery versus resection was based on the
subjective appreciation of the mechanical stability expected after conservative treatment
by the surgical team managing the patient (Fig. 2). None of the patients presented
pathological fracture at the time of treatment.
Figure 2. Intraoperative view after curettage. Mechanical reaming as a complement to

curettage.
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The intervention consisted of meticulous curettage completed by mechanical reaming of
the walls, then filling the intraosseous cavity with polymethylmethacrylate cement.
Before polymerization of the cement, the curetted zone submerged in cement was fixed
with an internal fixator to ensure optimal mechanical stability in 16 cases (11 plates, three
plates + screws, and two with screws alone) (Fig. 3).
Figure 3. X-ray at 4 years of follow-up. No sign of osteoarthritis, no scalable border.
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Adjuvant treatment was given in five cases: in three cases, an aqueous solution of 80%
phenol was applied on the curetted wall with a compress, then rinsed in pure alcohol; this
procedure was repeated three times. In two cases, a diphosphonate perfusion was given
postoperatively.
The mean follow-up of this series was 6 years and 4 months (range, 7 months to 13
years).
None of the patients was lost to follow-up.
Results
Oncological results
During the clinical and radiological follow-up of the patients who had received this
treatment, nine recurrences (30%) were identified. Seven occurred in the 2 years
following surgery (mean, 19 months ± 10 months; range, 10–38 months).
Recurrence was diagnosed based on visualization of a progressive scalable border on the
plain X-rays taken during the follow-up visits. MRI confirmed this and demonstrated the
extension of the recurrence.
In six cases, the recurrence was found in the lower extremity of the femur. Three patients
were treated with total knee arthroplasty, three with a second curettage and cementation
procedure. One recurrence at the upper tibia, one at the lower tibia, and one in the wrist
were also treated with a second curettage and cementation procedure.
Of these recurrences, seven were in contact with the cartilage, two with extension to soft
tissues.
The mean follow-up of these recurrences was 5.5 years ± 3 years (range, 1–13 years).
At the last follow-up of this study, no recurrence after a second curettage and
cementation treatment was noted.
Functional results
At the last follow-up, the function of the operated limb was studied using the MSTS score
described by Enneking et al. [8] to evaluate the functional result after tumor surgery.
The MSTS takes into account pain, function, acceptance of the surgery, as well as
assistance, limping, and walking distance for the lower limb or position for the hand, and
dexterity or elevation for the upper limb. In this series, the score was a mean 93.33%
(mean MSTS score, 28 ± 2/30).
Radiographic results
At the last follow-up, four nonprogressive scalable borders (15%) were found on plain
radiographs out of 26 patients (Fig. 3). The four patients who had had total knee
replacement had normal X-rays during the last follow-up visit, with no loosening, no
wear, and no sign of recurrence.
We also noted two cases of minimal osteoarthritis (one impingement < 50% one simple
condensation of the chondral bone) requiring simple monitoring, one at the talocrural
joint and one at the upper extremity of the tibia, responsible for genu varum with little
progression. In these two cases, the tumor was located at the contact with the cartilage,
with extension to soft tissues. None of these cases of osteoarthritis was symptomatic and
did not require surgical revision.
Early complications
Three complications were found, one case of sural phlebitis and one hematoma at the
operative site, which was not revised. One patient developed sepsis in the surgical zone
(upper tibia) 2 months after curettage and cementation. We treated it with removal of the
cement, lavage, then filling with autograft plus biomaterials; the patient has experienced
no new septic complications.
Discussion
Treating GCT with curettage and cementation was described by Vidal [9] in 1969; since
then, this technique has become current practice for treating this type of tumor, adopted
by a large number of surgical teams. Nevertheless, several questions remain concerning
the recurrence rate after performing this technique, the toxic effect of the cement on
cartilage, and the value of systematic osteosynthesis.
It is commonly accepted that the tumor recurrence rate after curettage and cementation
treatment including filling with analogous tissue or simple allograft, i.e., with no
adjuvant, ranges from 30 to 55% depending on the series [1], [2], [3], [6], [10], [14] and
[15]. Use of an adjuvant reduces the recurrence rate. Several methods have been
proposed, for example, use of a chemical agent such as phenol, but the concentrations of
this product authorized in France are too low to make it effective [1] and [11].
Use of liquid nitrogen results in a 2–8% recurrence rate [4], [9] and [12], but this is a
difficult technique with frequent complications, 30% according to Babinet [1]. Its use
therefore remains rare in France.
Use of the cytotoxic properties of the cement can reduce the recurrence rate to between
17 and 25% [1], [2], [13], [14] and [16]. The present study had a 30% recurrence rate
during the first 2 years, corresponding to a modest benefit in terms of recurrence.
This technique is criticized for its arthrogenic potential. GCT occur around the
metaphyseal–epiphyseal area of long bones and are therefore close to the joint cartilage.
In our study, 73% were in contact with the joint cartilage. However, we only found 10%
minimal osteoarthritis at the last follow-up, with no functional repercussions. In addition,
the causal relation between the intervention and the beginning of osteoarthritis cannot be
reliably established, whatever the volume of cementation. This was confirmed by a
March 2007 study in Sweden conducted by Vult von Steyern et al. [7], which noted no
osteoarthritis progression at 9 years of follow-up. Moreover, the mean MSTS score of
93.33% (28 ± 2/30) shows that the functional result of this surgery is excellent at the
longest follow-up.
Even though, no clinical study recommends systematic osteosynthesis to reinforce the
cementation after curettage, we believe this is warranted. Babinet [1] described a bead
effect (Fig. 4), rolling of the remainders of the tibial plateau on the cement block,
resulting in treatment failure. Osteosynthesis could prevent this failure mechanism by
interlocking the cement with the bony shell left in place, thus promoting peripheral bone
repair. No bead effect was found in our series, in which 16 patients (53.33%) had
osteosynthesis reinforcement whenever curettage left a substantial cavity volume.
Figure 4. A. Window for curettage cementation. B. The subchondral bone fractures. C.

The remainder of the tibial plateau between A and B rolls on the cement block [1]. Plate
osteosynthesis prevents this effect.
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Finally, curettage and cementation treatment allowed for early detection of recurrence
[6], [10], [16] and [17] and therefore, early management. The cement forms a
radiologically homogeneous and dense mass, with the appearance of a progressive
scalable border at the cement–bone interface that is highly suggestive of recurrence,
underscoring the importance of radiological follow-up every 4 months for the first 2
years in our view.
Conclusion
GCT can be treated easily and reproducibly with curettage and cementation with
excellent and long-lasting functional results at the medium term. The arthrogenic effect
that has been blamed on the cement coming in contact with cartilage has never been
clearly demonstrated, even when used for filling voluminous cavities. In addition, the
results of the series presented herein showed that none of the patients treated with
curettage and cementation suffered from secondary symptomatic osteoarthritis. All the
mechanical and cytotoxic properties of the cement, as well as its innocuousness and ease
of handling give it the top ranking in treatment of GCT, associated with osteosynthesis
materials in cases of large cavities after curettage in our study. The 30% recurrence rate
shows that acrylic cement plays a small role as adjuvant. Other complementary
treatments such as diphosphonate or calcitonin are currently being studied in an attempt
to reduce the recurrence rate.
References
[1] Babinet A. Tumeur à cellule géantes : cahier d’enseignement de la Sofcot. Elsevier

SAS : Paris : France 2005:201–19.
[2] M. Campanacci, N. Baldini, S. Boriani and A. Sudanese, Giant cell tumor of bone, J
Bone Joint Surg Am 69 (1987), pp. 106–114. View Record in Scopus | Cited By in
Scopus (266)
[3] H.W. Sung, D.P. Kuo, W.P. Shu, Y.B. Chai, C.C. Liu and S.M. Li, Giant cell tumor
of bone: analysis of 208 cases in Chinese patient, J Bone and Joint Surg Am 64 (1982),
pp. 755–761. View Record in Scopus | Cited By in Scopus (114)
[4] M.M. Malawer, J. Bickels, I. Meller, R.G. Buch, R.M. Henshaw and Y. Kollender,
Cryosurgery in the treatment of giant-cell tumor: a long-term follow-up study, Clin
Orthop 359 (1999), pp. 176–188. Full Text via CrossRef | View Record in Scopus | Cited
By in Scopus (107)
[5] R.C. Marcove, L.D. Weis, M.R. Vaghaiwalla, R. Person and A.G. Huvos,
Cryosurgery in the treatment of giant-cell tumors of bones. A report of 52 consecutive
cases, Cancer 41 (1978), pp. 957–969. Full Text via CrossRef | View Record in Scopus |
Cited By in Scopus (68)
[6] Turcotte RE, Isler M, Doyon J. Tumeur à cellules géantes. In: Encyclopédie
médicochirurgicale : appareil locomoteur : Paris : France :Elsevier SAS 2001 : 14–772.
[7] F. Vult Von Steyern, I. Kristiansson, K. Jonsson, P. Mannfolk, D. Heinegård and A.

Rydholm, Giant-cell tumour of the knee. The condition of the cartilage after treatment by
curettage and cementing, J Bone Joint Surg Br 89 (2007), pp. 361–365. View Record in
Scopus | Cited By in Scopus (9)
[8] W.F. Enneking, W. Dunham and M.C. Gebhardt et al., A system for the functional
evaluation of reconstructive procedures after surgical treatment of tumors of the
musculoskeletal system, Clin Orthop Relat Res 286 (1993), pp. 241–246. View Record in
Scopus | Cited By in Scopus (703)
[9] J. Vidal, R. Mimran and Y. Allieu, Plastie de comblement par méthacrylate de

méthyle traitement de certaines tumeurs osseuses bénignes, Montpellier chirurgical tome
15 (1969), pp. 389–397.
[10] M. Szendroi, Giant-cell tumor of bone, J Bone and Joint Surg Br 86 (2004), pp. 5–
11.
[11] R.E. Turcotte, J.S. Wunder, M.H. Isler, R.S. Ell, N. Schasar and B.A. Masri et al.,
Giant cell tumor of long bone: a Canadian Sarcoma Group study, Clin Orthop Relat Res
397 (2002), pp. 259–270.
[12] R.C. Marcove, J.P. Lyden, A.G. Huvos and P.B. Bullough, Giant-cell tumors treated
by cryosurgery: a report of 25 cases, J Bone Joint Surg Am 55 (1973), pp. 1633–1644.
View Record in Scopus | Cited By in Scopus (33)
[13] R.J. O’Donnell, D.S. Springfield and H.K. Motwani et al., Recurrence of giant-cell
tumours of the long bones after curettage and packing with cement, J Bone Joint Surg
Am 76 (1994), pp. 827–833.
[14] R. Capanna, N. Fabbri and G. Bettelli, Curettage of giant cell tumor of bone. The
effect of surgical technique and adjuvants on local recurrence rate, Chir Org Mov 75
(Suppl. 1) (1990), p. 206. View Record in Scopus | Cited By in Scopus (40)
[15] H.R. Blackley, J.S. Wunder, A.M. Davis, L.M. White, R. Kandel and R.S. Bell,
Treatment of giant-cell tumors of long bones with curettage and bone-grafting, J Bone
Joint Surg Am 81 (1999), pp. 811–820. View Record in Scopus | Cited By in Scopus (87)
[16] D. Remedios, A. Saifuddin and J. Pringle, Radiologic and clinical recurrence of
giant cell tumor of bone after the use of cement, J Bone Joint Surg Br 79 (1997), pp. 26–
30. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (38)
[17] A. Stefano, K.O. Gill and J. Johnston, Giant cell tumor of bone curettage and cement
reconstruction, Clin Orthop Relat Res 321 (1995), pp. 245–250.
Corresponding author.
Ulnar translocation after excision of a Campanacci
grade-3 giant-cell tumour of the distal radius
AN EFFECTIVE METHOD OF RECONSTRUCTION
A. Puri, MS(Orth), Associate Professor1; A. Gulia, MS(Orth), Fellow1; M. G.
Agarwal, MS(Orth), DNB, Associate Professor1; and K. Reddy, MS(Orth), Fellow1
1
Tata Memorial Hospital, E Borges Road, Parel, Mumbai, 400 012, India.
Correspondence should be sent to Dr A. Puri; e-mail: docpuri@vsnl.com
Abstract
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Between June 2005 and March 2008, 14 patients with a Campanacci grade-3 giant-cell
tumour of the distal radius were treated by en bloc resection and reconstruction by ulnar
translocation with arthrodesis of the wrist. The mean length of radius resected was 7.9 cm
(5.5 to 15). All the patients were followed to bony union and 12 were available at a mean
follow-up of 26 months (10 to 49).
The mean time to union was four months (3 to 7) at the ulnocarpal junction and five
months (3 to 8) at the ulnoradial junction. All except one patient had an excellent range of
pronation and supination. The remaining patient developed a radio-ulnar synostosis. The
mean Musculoskeletal Tumor Society score was 26 (87%, range 20 to 28). Three patients
had a soft-tissue recurrence, but with no bony involvement. They underwent a further
excision and are currently well and free from disease.
Ulnar translocation provides a local vascularised bone graft to reconstruct the defect left
after excision of the distal radius for giant cell tumour. It avoids the need for a
microvascular procedure while retaining rotation of the forearm and good function of the
hand.
Introduction
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The distal end of the radius is the third most common site for a giant-cell tumour (GCT)
with approximately 10% occurring at this location.1 The aims of treatment are complete
removal of the tumour while preserving maximum function of the limb. In most cases this
can be achieved by curettage and by packing the cavity with bone graft or
methylmethacrylate cement. In some cases, especially those in which the tumour has
broken through the cortex (Campanacci grade 3),1 has grown rapidly, or when there is
local recurrence with a large soft-tissue component, the distal end of the radius has to be
resected and reconstructed.2–6 This can be achieved either by arthroplasty or arthrodesis
using vascularised or non-vascularised autografts from the tibia, proximal fibula, iliac
crest or distal ulna.7–11 Other procedures include the use of an osteoarticular allograft,
transposition of the carpus on to the distal part of the ulna to create a one-bone forearm or
a custom-made prosthesis.5,12,13
Although first described more than 25 years ago by Seradge,14 translocation of the
ipsilateral ulna as a vascularised strut graft, has only been mentioned occasionally in the
literature. To the best of our knowledge, only 11 cases have been reported.9,15–17
Our aim was to evaluate the results of translocation of the ulna with arthrodesis of the
wrist after resection of a Campanacci grade-3 GCT of the distal radius. We examined the
complications of the technique, the time taken to union and the functional outcome.
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Between June 2005 and March 2008, 14 patients (Table I) with a Campanacci grade-3
GCT of the distal radius (Fig. 1) were treated by en bloc excision, translocation of the
ipsilateral ulna and arthrodesis of the wrist. They were identified by retrospective review
from a prospectively maintained database. Their medical records, imaging and functional
status were reviewed. There were seven men and seven women with a mean age of 31.6
years (16.0 to 55.0). All were right-handed. The right radius was affected in nine patients
and the left in five. Seven presented with recurrent disease. The mean duration of
symptoms before presentation was 3.6 months (2.0 to 6.0).
View this table: Table I. Details of the 14 patients and the results
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Fig. 1a, Fig. 1b Pre-operative anteroposterior a) and lateral radiographs b)

of a patient with a giant-cell tumour of the distal radius.
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A tissue diagnosis was obtained for all the primary tumours. Only those recurrent tumours
in which the histological findings from the previous lesion were not available were
subjected to a further biopsy. We used a core-needle biopsy technique and were satisfied
with its yield and accuracy.18 Imaging studies included plain radiography, MRI of the
wrist and chest radiography. MRI was used to evaluate the extent of the lesion, its
extraosseous component, its relation to the neurovascular bundle and to place the level of
transection of the bone. The mean length of bone resected was 7.9 cm (5.5 to 15.0).
Operative technique.
The radial lesion was excised en bloc with the surrounding soft tissue and pronator
quadratus muscle in order to avoid contamination of the remaining tissue with tumour.
After division of the adjacent ulna at the appropriate level, the distal ulna with its retained
muscle attachment was transposed into the bony defect, denuded of cartilage and apposed
to the cancellous surface of the similarly prepared scaphoid and lunate. Before
transposing the ulna, care was taken to ensure that the periosteal sleeve had been
completely divided around the ulna at the level of the proximal osteotomy. Without
disrupting the retained muscle attachment, the transposed ulna was aligned with the
radius and the second or third metacarpal so that the forearm retained full pronation and
supination, and then internally fixed. In the first two patients we used an intramedullary
nail passed proximally from the metacarpal, but changed to plate-and-screw fixation for
the next 12 in order to obtain a more stable reconstruction. No patient had junctional bone
grafting at their first operation.
Except for the first two patients who were immobilised in an above-elbow splint for eight
weeks, all the others had a below-elbow splint for six weeks. Active shoulder, elbow and
finger mobilisation was encouraged in the immediate post-operative period.
The patients were seen every three months for the first two years and every six months
thereafter. Radiographs of the wrist were assessed at each visit. A chest radiograph was
evaluated every six months for evidence of metastases. The functional status was
determined at the final follow-up using the Musculoskeletal Tumor Society scoring
system.19 This was based on the analysis of three factors of pain, functional activities and
emotional acceptance, pertinent to the patient as a whole, and three specific to the upper
limb namely positioning of the hand, manual dexterity and lifting ability. For each of the
six factors, values of 0 to 5 were assigned based on established criteria. The result was
expressed as a sum total with a maximum score of 30 and as a percentage of the expected
normal function for the patient. The mean follow-up was for 26 months (10 to 49).
Results
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Two patients developed superficial skin necrosis and one a superficial wound infection.
All settled with conservative management. All 14 patients were followed to bony union.
A total of 12 patients were available at the final review. The mean time to radiological
union was 4.4 months (3.0 to 7.0) at the ulnocarpal junction and 4.9 months (3.0 to 8.0) at
the ulnoradial junction (Fig. 2). No patient required an additional procedure to augment
union. All except one patient had excellent pronation and supination. The remaining
patient developed a radio-ulnar synostosis and had no rotation of the forearm. In these 12
patients the mean Musculoskeletal Tumor Society score was 26 (87%; 20 to 28).
Fig. 2a, Fig. 2b Anteroposterior a) and lateral radiographs b) 12 months

after ulnar translocation for patient number 4.
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Three patients had a local soft-tissue recurrence with no bony involvement. The
recurrences were excised. One also had subsequent pulmonary metastases and underwent
their excision. All three patients are currently well and free from disease. One patient had
a fall one year after the procedure and sustained a fracture through the transposed ulna.
He underwent further internal fixation with uneventful union.
Discussion
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Discussion
References
GCT of the distal radius is a condition which allows excision of the tumour while
preserving excellent function of the wrist and hand. While excision may not be mandatory
in every case it has been suggested that this rather than intralesional curettage may be
preferred to reduce the incidence of local recurrence, particularly if the tumour has
breached the cortex, violated the articular surface or destroyed more than half of the
surrounding metaphysis.20
Reconstruction after excision of the distal radius for GCT is a challenge because of the
high functional demands on the hand, the limited surrounding soft tissue, the proximity of
adjacent nerves and tendons and the young age and relatively long life expectancy of this
group of patients.5
Various factors need to be considered when evaluating a technique of reconstruction.
These include the ease of the procedure, its morbidity, the complications and functional
outcome and the durability of the reconstructed segment.
The use of an avascular strut autograft is often limited by the long length of the resection
gap and by donor-site morbidity. When the upper fibula is used there is arisk of persistent
pain in the leg, laxity of the lateral ligament at the knee, palsy of the peroneal nerve and
dysaesthesia in the back of the leg.10 Strut allografts, although a useful option, are limited
by their availability and are associated with nonunion, fracture, infection and the fear of
transmission of disease.5,21 The use of custom-made endoprostheses for tumours of the
distal radius is limited.13,22
Whether vascularised or non-vascularised bone grafts are used, defects of the distal radius
can be reconstructed either by arthroplasty or arthrodesis. Various authors have reported
that for extraosseous GCTs in this region, the best clinical results are seen in patients who
have been treated by radiocarpal arthrodesis.2,11,20,21,23
Ipsilateral ulnar transfer is an easy, inexpensive technique which does not require
microvascular skills. It is also quicker to perform than free vascularised fibular grafting.
The reduction in volume of the forearm from the radial displacement of the ulna
facilitates skin closure after excision of the tumour, especially in cases in which a
fungating lesion or extensive soft-tissue involvement has resulted in loss of soft tissue and
skin. Since the surgical procedure is restricted to the same limb morbidity is reduced. The
shorter surgical procedure and the fact that a graft which retains its blood supply has been
used possibly help to reduce infection. Retaining the vascularity of the graft also
improves the chances of union which is quicker than that of a non-vascularised
graft.2,20,23,24
Ensuring that the periosteal sleeve has been completely divided at the level of the ulnar
osteotomy may prevent postoperative radio-ulnar synostosis. Failure to divide the
proximal periosteum circumferentially causes it to shear off from the end of the divided
ulna as it is being transposed. This may not only impair the vascularity of the transposed
bone, but may result in the formation of bone along the retained periosteal bridge thereby
limiting rotation of the forearm.
Unlike Chalidis and Dimitriou15 we do not advocate routine tenodesis of the extensor or
flexor carpi ulnaris since we have not found that there is any cosmetic or functional
disturbance. An ancillary benefit of the resultant one-bone forearm is that the problems
associated with ulnar variance which may occur after reconstruction with the fibula, iliac
crest or allograft, can be avoided.5,10,20,24 Despite creating a one-bone forearm, this
technique retains forearm rotation (Fig. 3). This is not possible when the ulna is fused
directly to the carpus12 which causes considerable functional difficulty.
Fig. 3 Photographs showing forearm rotation after ulnar

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The most common complication of this procedure in earlier descriptions was delayed
union or nonunion of the proximal radio-ulnar junction. This required revision of the
internal fixation and autogenous cancellous bone grafting.16 The use of a longitudinal pin
to stabilise the radio-ulnar junction probably allowed micromovement at the site of the
osteotomy resulting in a low rate of union. We now use plates and screws to stabilise the
construct since this gives better fixation and provides a better biological and mechanical
environment for bony union.15,24 This is probably why no additional procedures were
needed to promote union. The stable fixation also enabled us to use a below-elbow splint
which allowed early active movement of the shoulder, elbow and fingers.
Although local recurrence of tumours is not a reflection of the technique of reconstruction
which has been used we have mentioned it in our results. The incidence of local
recurrence in our series of 25% is in keeping with that described in the literature for
Campanacci grade-3 GCTs of the distal radius.4
Ulnar translocation is an easy, inexpensive method of reconstructing the distal end of the
radius after excision for a GCT. It avoids the need for a microvascular procedure and
gives excellent rotation of the forearm and function of the hand.
Footnotes
No benefits in any form have been received or will be received from a commercial party
related directly or indirectly to the subject of this article.
Received for publication August 3, 2009. Accepted for publication January 28, 2010.
References
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References
Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J

Bone Joint Surg [Am] 1987;69-A:106–14.
Vander Griend RA, Funderburk CH. The treatment of giant-cell tumors of the
distal part of the radius. J Bone Joint Surg [Am] 1993;75-A:899–908.
Sheth DS, Healey JH, Sobel M, Lane JM, Marcove RC. Giant cell tumor of the
distal radius. J Hand Surg [Am] 1995;20:432–40.[Medline]
Khan MT, Gray JM, Carter SR, Grimer RJ, Tillman RM. Management of the
giant-cell tumours of the distal radius. Ann R Coll Surg Engl 2004;86:18–24.
[CrossRef]HYPERLINK "/cgi/external_ref?
access_num=15005940&link_type=MED"[Medline]
Kocher MS, Gebhardt MC, Mankin HJ. Reconstruction of the distal aspect of the
radius with use of an osteoarticular allograft after excision of a skeletal tumor. J
Bone Joint Surg [Am] 1998;80-A:407–19.
Harness NG, Mankin HJ. Giant-cell tumor of the distal forearm. J Hand Surg [Am]
2004;29:188–93.[CrossRef]HYPERLINK "/cgi/external_ref?
Campbell CJ, Akbarnia BA. Giant-cell tumor of the radius treated by massive
resection and tibial bone graft. J Bone Joint Surg [Am] 1975;57-A:982–6.
Leung PC, Chan KT. Giant cell tumor of the distal end of the radius treated by the
resection and free vascularised iliac crest graft. Clin Orthop 1986;202:232–6.
[Medline]
Turcotte RE, Wunder JS, Isler MH, et al. Giant cell tumor of long bone: a
Canadian Sarcoma Group study. Clin Orthop 2002;397:248–58.
Murray JA, Schlafly B. Giant-cell tumors in the distal end of the radius: treatment
by resection and fibular autograft interpositional arthrodesis. J Bone Joint Surg
[Am] 1986;68-A:687–94.
Ono H, Yajima H, Mizumoto S, et al. Vascularized fibular graft for reconstruction
of the wrist after excision of giant cell tumor. Plast Reconstr Surg 1997;99:1086–
93.[CrossRef]HYPERLINK "/cgi/external_ref?
access_num=A1997WM06000026&link_type=ISI"[Web of
Science]HYPERLINK "/cgi/external_ref?
Bhagat S, Bansal M, Jandhyala R, et al. Wide excision and ulnocarpal arthrodesis
for primary aggressive and recurrent giant cell tumours. Int Orthop 2008;32:741–
5.[CrossRef]HYPERLINK "/cgi/external_ref?
access_num=000262490700004&link_type=ISI"[Web of Science]HYPERLINK
"/cgi/external_ref?access_num=17643243&link_type=MED"[Medline]
Natarajan MV, Chandra Bose J, Viswanath J, Balasubramanian N, Sameer M.
Custom prosthetic replacement for distal radial tumours. Int Orthop
2009;33:1081–4.[CrossRef]HYPERLINK "/cgi/external_ref?
Seradge H. Distal ulnar translocation in the treatment of giant-cell tumors of the
distal end of the radius. J Bone Joint Surg [Am] 1982;64-A:67–73.
Chalidis BE, Dimitriou CG. Modified ulnar translocation technique for the
reconstruction of giant cell tumour of the distal radius. Orthopedics 2008;31:608.
[Medline]
Bhan S, Biyani A. Ulnar translocation after excision of giant cell tumour of distal
radius. J Hand Surg Br 1990;15:496–500.[Abstract/Free Full Text]
Lalla R, Bhupathi SC. Treatment of giant cell tumor of the distal radius by ulnar
translocation: a case report and review of the literature. Orthopedics
1987;10:735–9.[Web of Science]HYPERLINK "/cgi/external_ref?
Pramesh CS, Deshpande MS, Pardiwala DN, Agarwal MG, Puri A. Core needle
biopsy for bone tumours. Eur J Surg Oncol 2001;27:668–71.
Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system
for the functional evaluation of reconstructive procedures after surgical treatment
of tumors of the musculoskeletal system. Clin Orthop 1993;286:241–6.[Medline]
Cheng CY, Shih HN, Hsu KY, Hsu RW. Treatment of giant cell tumor of the distal
radius, Clin Orthop 2001;383:221–8.[CrossRef]HYPERLINK "/cgi/external_ref?
Asavamongkolkul A, Waikakul S, Phimolsarnti R, Kiatisevi P. Functional
outcome following excision of a tumour and reconstruction of the distal radius.
Int Orthop 2009;33:203–9.[CrossRef]HYPERLINK "/cgi/external_ref?
Hitaro H, Morita T, Kobayashi H, Otsuka H. A ceramic prosthesis for the
treatment of tumours of the distal radius. J Bone Joint Surg [Br] 2006;88-
B:1656–8.[Abstract/Free Full Text]
Minami A, Kato H, Iwasaki N. Vascularized fibular graft after excision of giant-cell
tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis. Plast
Reconstr Surg 2002;110:112–17.[CrossRef]HYPERLINK "/cgi/external_ref?
Hackbarth DA Jr. Resections and reconstructions for tumors of the distal radius.
Orthop Clin North Am 1991;22:49–64.[Web of Science]HYPERLINK
Modified Ulnar Translocation Technique for the Reconstruction of Giant Cell
Tumor of the Distal Radius
Byron E Chalidis, Christos G Dimitriou. Orthopedics (Online). Thorofare: Jun 2008.
Vol. 31, Iss. 6; pg. 1, 6 pgs
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Full Text
(2196 words)
Copyright SLACK INCORPORATED Jun 2008
Giant cell tumors of the distal radius have been frequently described as difficult to treat,
chiefly because of their close proximity to multiple tendons, median nerve, radial artery
and carpus.1 The aim of treatment is to remove the tumor completely and preserve the
radiocarpal and radioulnar joints.2 However, this is not always feasible as giant cell
tumors seem to behave more aggressively and have a higher recurrence rate in the distal
radius, even if local adjuvant treatment with phenolmethylmethacrylate or liquid nitrogen
is applied.1-4 The above incidence is increased in Campanacci grade III lesions, which
are characterized by fuzzy borders, loss of cortical continuity, and extension into soft
tissues.1,4 In these cases, wide excision instead of intralesional excision may be
advocated, particularly when the tumor breaks through the cortex, violates the articular
surface, and destroys >50% of the surrounding metaphysis.2
Several reconstructive options (eg, resection arthroplasty, prosthetic replacement,
arthrodesis, ulnar translocation, centralization of the carpus over the remaining ulna, use
of a nonvascularized, or vascularized fibular graft [with or without arthrodesis], and
allograft replacement) have been described for the treatment of either recurrent or
primary grade III giant cell tumor with destruction of the bone cortex and associated soft
tissue mass.5,6 Ulnar translocation has been mentioned rarely in the literature, and,
according to our knowledge, only 10 cases have been previously reported.7-10
This article presents a case of a woman with a grade III giant cell tumor of the distal
radius. Wide excision of the tumor followed by reconstruction of the distal forearm with
a modified ulnar translocation technique and wrist arthrodesis led to optimum results and
no mass recurrence at 13 years postoperatively.
Case Report
A 66-year-old, female, right-hand dominant farmer presented with a 5-month history of
gradually increasing pain and swelling of the right wrist. The distal forearm was tender to
palpation, and carpal movements were painful. Plain radiographs revealed a lytic osseous
lesion with permeative margins at the distal end of the radius. Loss of cortical continuity,
invasion of the articular surface, and tumor extension into the soft tissues were also
apparent. Computed tomography (CT) clearly demonstrated the cortical destruction and
extraosseous mass in the volar side of the distal radius. Technetium-99 bone scan showed
increased uptake of the radioactive material at the right wrist compared with the opposite
side and no evidence of distant metastasis (Figure 1). Examination of the biopsy
specimen confirmed the true nature of the lesion, and the decision for wide excision and
ulnar translocation was taken. The applied procedure was a modification of the standard
technique initially described by Seradge.8
A dorsal lazy S incision (incorporating the biopsy margins) was performed from the
diaphysis of third metacarpal to the middle third of right forearm. After dissection of the
extensor retinaculum and protection of the extensor tendons and radial sensory nerves,
the lesion was carefully exposed. The radius was osteotomized in a normal-appearing
bone area (approximately 2 cm from the proximal end of tumor), and the distance
between radial osteotomy and proximal edge of the capitate was measured. Thereafter, en
bloc resection of the distal radius was carried out together with the surrounding soft
tissues, distal interosseous membrane, and pronator quadratus muscle. No chemical
adjuvant was used, and samples were sent for histological examination to ensure
resection into healthy tissue.
Using a rongeur and small osteotomes, the lunate was completely removed, and the bed
for wrist arthrodesis was prepared with denution of articular cartilage from all midcarpal
and carpometacarpal joints. Particularly, a rounded space in the proximal carpal row
between the scaphoid, capitate, hamate, and triquetrum was created for graft insertion.
The ulna was subsequently osteotomized through the same incision, and a bone segment
of appropriate length (equal to the distance between radial osteotomy and capitate) with
the periosteum and muscular attachments was received. After resection of its distal
articular surface, the ulnar graft was adjusted to fit properly to the previously created
carpal space and in alignment to the axis of capitate, third metacarpal, and radial
diaphysis (Figure 2).
Ultimately, the wrist was positioned in slight dorsiflexion and ulnar deviation. A dorsal
12-hole titanium 3.5-mm dynamic compression plate was implanted from the third
metacarpal to radial diaphysis and additional iliac crest bone graft was inserted at both
ends of the sliding ulnar graft to enhance the fusion process. Harvesting of bone graft
from the anterior ilium was performed with a separate set of instruments to avoid
potential cross contamination. Finally, the surgical wound was closed, and a bridging
wrist external fixator was applied for further stability and continuous evaluation of the
wound and vascular status (Figure 3).
One month postoperatively, the wound had healed uneventfully and the external fixation
was removed after the first signs of bone healing. According to histologic results, the
surgical margins were free of disease. At 13-year followup, the patient was pain free and
still working as a farmer. She had 70° of supination and 60° of pronation. The grip
strength of the operated hand was 80% compared with the contralateral side. Radiographs
of the wrist and forearm showed incorporation of the ulnar graft distally and proximally,
maintenance of wrist position, and no tumor recurrence (Figure 4).
Discussion
All of the described surgical procedures for the reconstruction of the complete defect that
is created after en bloc resection of the distal radius have shown fair functional outcomes
with regard to patient satisfaction or ability to return to a normal life and notable
complication rates.6,11 The most favorable options have used either autologous
vascularized and nonvascularized grafts or osteoarticular allografts, with or without wrist
arthrodesis.2,12-15 It seems that the functional benefit of wrist joint preservation after
transplantation of a radial allograft or vascular fibula cannot outweigh the risks of pain,
weakness, subluxation, and degenerative arthritis because of the relative incongruity of
the newly formed joint and the subsequent ligament instability.2,14
Vander Griend and Funderburk15 reported that in extraosseous giant cell tumors of the
distal radius, the best clinical results were seen in patients who had been managed with
radiocarpal arthrodesis and use of an intercalary bone graft that was stabilized with a long
plate. Furthermore, at the most recent follow-up examination (range, 2-19 years), there
had been no local recurrences. In a comparative study, Minami et al11 found that wrist
arthrodesis with a vascularized fibular shaft graft was a more useful and reliable
procedure for wrist reconstruction after wide excision of a giant cell tumor from the distal
end of the radius than wrist arthroplasty using the vascularized fibular head. We believe
that rigid wrist arthrodesis could offer immediate inherent stability, pain relief, and good
grip strength, despite the loss of flexion-extension range of motion.
Translocation of the ulna to the distal radial defect with carpoulnar arthrodesis was
performed in 2 patients reported on by Seradge,8 6 patients reported on by Bhan and
Biyani9, 1 patient reported on by Lalla and Bhupathi7 and 1 patient reported on by
Turcotte et al10. The distal fusion was carried out to a slot between the scaphoid and
lunate, and stabilization was achieved with a long Steinmann pin driven from the third
metacarpal and lunate to the medullary cavity of the proximal radius.8 The patients had
good grip strength and forearm rotation without the proximal stump to cause cosmetic or
functional disturbances. The latter finding, which was additionally apparent in the
presented case, doesn't preclude the necessity of stabilizing the ulnar stump, as
impingement and dynamic radioulnar convergence could be due to the proximally located
ulnar osteotomy.16 We advocate extensor or flexor carpi ulnaris tenodesis and
postoperative immobilization of the radioulnar site as the operative protocol and that it be
performed routinely in similar cases.
In previously published cases, the forearm at the distal part became thin, but no
postoperative fractures or severe functional impairment were described.7-10 The
translocated ulna was slightly hypertrophied due to its adaptation in the axial transmitted
forces, but it was insufficient to withstand the stresses of strenuous activities.8,9 Besides
promoting bone healing at both sides of the sliding ulnar fragment, the introduction of the
massive iliac bone graft in the current patient aimed to reinforce the 1-bone configuration
of the distal forearm, eliminating the possibility of fragment fracture or failure. As a
result, the grafting area obtained a more solid and bulky appearance, and the patient was
able to participate in farming activities without restriction.
The most common complication of the initially described technique was the delayed
union or nonunion of the proximal radioulnar site necessitating revision internal fixation
with autogenous cancellous bone grafting in 5 of the 10 reported patients. Bhan and
Biyani9 stated that despite the fact that the ipsilateral translocated ulna preserves its
periosteal blood supply due to the undisturbed soft tissue attachments, its osteogenic
potential is limited. The use of a longitudinal pin to stabilize the radioulnar junction
probably could not block rotation in the forearm and resulted in micromotion at the
osteotomy site and low union rate. In the current case, iliac crest grafting and plate
osteosynthesis (instead of Steinmann pin) provided a better biological and mechanical
environment for bone union. Therefore, early fusion was achieved and no additional
procedures were deemed necessary.
In comparison with the standard technique, we completely removed the lunate and not a
segment of the bone. The created space increases the bone contact surface and offers
better rotational stability. Moreover, the capitate is a more reliable landmark for the
estimation of the appropriate length of the resected bone and, consequently, of the
intercalary graft when destruction of the radiocarpal joint or lunate is evident. The above
modification, in conjunction with total wrist arthrodesis via a dorsal plate from the radius
to third metacarpal, may eliminate the loss of wrist position noticed by Lalla and
Bhupathi7 in their case.
The modified ulnar translocation technique for the treatment of giant cell tumors of the
distal radius may offer better results regarding the parameters of wrist stability and bone
union. However, due to the small number of published cases, neither the overall effect of
the method nor the advantages of its modification could be clearly assessed.
[Reference]
References
1. Harness NG, Mankin HJ. Giant-cell tumor of the distal forearm. J Hand Surg Am. 2004;
29(2):188-193.
2. Cheng CY, Shih HN, Hsu KY, Hsu RW. Treatment of giant cell tumor of the distal radius.
Clin Orthop Relat Res. 2001; (383):221-228.
3. Gitelis S, Mallin BA, Piasecki P, Turner F. Intralesional excision compared with en bloc
resection for giantcell tumors of bone. J Bone Joint Surg Am. 1993; 75(11):1648-1655.
4. O'Donnell RJ, Springfield DS, Motwani HK, Ready JE, Gebhardt MC, Mankin HJ.
Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J
Bone Joint Surg Am. 1994; 76 (12):1827-1833.
5. Kocher MS, Gebhardt MC, Mankin HJ. Reconstruction of the distal aspect of the radius with
use of an osteoarticular allograft after excision of a skeletal tumor. J Bone Joint Surg Am. 1998;
80(3):407-419.
6. Szabo RM, Anderson KA, Chen JL. Functional outcome of en bloc excision and osteoarticular
allograft replacement with the Sauve-Kapandji procedure for Campanacci grade 3 giant-cell
tumor of the distal radius. J Hand Surg Am. 2006; 31(8):1340-1348.
7. Lalla RN, Bhupathi SC. Treatment of giant cell tumor of the distal radius by ulnar
translocation. A case report and review of the literature. Orthopedics. 1987; 10(5):735-739.
8. Seradge H. Distal ulnar translocation in the treatment of giant-cell tumors of the distal end of
the radius. J Bone Joint Surg Am. 1982; 64(1):67-73.
9. Bhan S, Biyani A. Ulnar translocation after excision of giant cell tumour of distal radius. J
Hand Surg Br. 1990; 15(4):496-500.
10. Turcotte RE, Wunder JS, Isler MH, et al. Giant cell tumor of long bone: a Canadian Sarcoma
Group study. Clin Orthop Relat Res. 2002; (397):248-258.
11. Minami A, Kato H, Iwasaki N. Vascularized fibular graft after excision of giant-cell tumor of
the distal radius: wrist arthroplasty versus partial wrist arthrodesis. Plast Reconstr Surg. 2002;
110(1):112-117.
12. Ihara K, Doi K, Sakai K, Yamamoto M, Kanchiku T, Kawai S. Vascularized fibular graft
after excision of giant cell tumor of the distal radius. A case report. Clin Orthop Relat Res. 1999;
(359):189-196.
13. Szabo RM, Thorson EP, Raskind JR. Allograft replacement with distal radioulnar joint
fusion and ulnar osteotomy for treatment of giant cell tumors of the distal radius. J Hand Surg.
1990; 15(6):929-933.
14. Aithal VK, Bhaskaranand K. Reconstruction of the distal radius by fibula following excision
of giant cell tumor. Int Orthop. 2003; 27(2):110-113.
15. Vander Griend RA, Funderburk CH. The treatment of giant-cell tumors of the distal part of
the radius. J Bone Joint Surg Am. 1993; 75(6):899-908.
16. McKee MD, Richards RR. Dynamic radio-ulnar convergence after the Darrach procedure. J
Bone Joint Surg Br. 1996;78(3):413-418.
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J Med Assoc Thai. 2008 Oct;91(10):1609-12.
Effectiveness of intravenous
bisphosphonate in treatment of giant cell
tumor: a case report and review of the
literature.
Arpornchayanon O, Leerapun T.
Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai,
Thailand.
Abstract
Giant cell tumor is a benign locally aggressive tumor. The standard treatment is en bloc
resection followed by major reconstructive surgery, or extended curettage conjunction
with bone grafting or the use of bone cement implantations. Surgical treatment of giant
cell tumor at the sacrum is associated with high morbidity, and local recurrence. The
authors present a case of giant cell tumor at the sacrum treated with intravenous 4 mg
zoledronate every 4 weeks for seven courses followed with curettage and cement
implantation. At two years follow-up, the patient had no pain, no neurological deficit, and
no local recurrence. The patient's gait was normal. From the present study, the authors
demonstrate the effectiveness of zoledronate for treatment of giant cell tumor at the
sacrum. It can reduce the morbidity from major surgery.
PMID: 18972907 [PubMed - indexed for MEDLINE]
Publication Types, MeSH Terms, Substances
Cytotoxic effect of drugs eluted from polymethylmethacrylate on stromal giant-cell

tumour cells: AN IN VITRO STUDY
D Gouran Savadkoohi, P Sadeghipour, H Attarian, S Sardari, et al. Journal of Bone and
Joint Surgery. (British volume). London: Jul 2008. Vol. 90, Iss. 7; pg. 973, 7 pgs
Abstract (Summary)
Curettage and packing with polymethylmethacrylate cement is a routine treatment for
giant-cell tumour (GCT) of bone. We performed an in vitro evaluation of the cytotoxic
effect of a combination of cement and methotrexate, doxorubicin and cisplatin on
primary cell cultures of stromal GCT cells obtained from five patients. Cement cylinders
containing four different concentrations of each drug were prepared, and the effect of the
eluted drugs was examined at three different time intervals. We found that the cytotoxic
effect of eluted drugs depended on their concentration and the time interval, with even
the lowest dose of each drug demonstrating an acceptable rate of cytotoxicity. Even in
low doses, cytotoxic drugs mixed with polymethylmethacrylate cement could therefore
be considered as effective local adjuvant treatment for GCTs.
» Jump to indexing (document details)
Full Text
(4432 words)
Copyright British Editorial Society of Bone & Joint Surgery Jul 2008
[Headnote]
Curettage and packing with polymethylmethacrylate cement is a routine treatment for giant-cell
tumour (GCT) of bone. We performed an in vitro evaluation of the cvtotoxic effect of a
combination of cement and methotrexate, doxorubicin and cisplatin on primary cell cultures of
stromal GCT cells obtained from five patients. Cement cylinders containing four different
concentrations of each drug were prepared, and the effect of the eluted drugs was examined at
three different time intervals.
We found that the cvtotoxic effect of eluted drugs depended on their concentration and the time
interval, with even the lowest dose of each drug demonstrating an acceptable rate of cytotoxicity.
Even in low doses, cvtotoxic drugs mixed with polymethylmethacrylate cement could therefore
be considered as effective local adjuvant treatment for GCTs.
A giant-cell tumour (GCT) has been described by the World Health Organisation as "an
aggressive, potentially malignant lesion."1 It remains one of "the most obscure and
intensively examined" tumours of bone.1 The three histological components of a GCT
are osteoclast-like giant cells which comprise most of the cells, monocytic round cells
and spindle-shaped fibroblast-like stromal cells. It is likely that the last represents the
neoplastic component of this tumour.2 Curettage and packing with pol ymethylmethacry
late (PMMA) is a form of treatment for a GCT3 because of "its accessibility, low price,
few complications and acceptable recurrence rate (9%)".4
PMMA can also be used as a skeletal drug-delivery system.5 Several investigators6-10
have described the use of bone cement containing antibiotics, and satisfactory results
have been reported in the treatment of chronic osteomyelitis and post-operative
infections.11 When chemotherapeutic agents such as doxorubicin,12 cisplatin12 and
methotrexate13 are added to PMMA they remain active against different tumours and
resist heat polymerisation.14 The compressive properties of PMMA do not seem to be
influenced by the addition of drugs.15
In this study we investigated the cytotoxic effects of the combination of PMMA and
antiblastic drugs including methotrexate, doxorubicin and cisplatin on stromal GCT cells
collected from five patients. In addition, in three patients a comparison was made
between the cytotoxic effects of these antiblastic drugs eluted from the cement on GCT
and intact bone tissue.
Per-operative specimens of GCT were taken from five patients on whom routine
preoperative histological and radiological confirmation of the diagnosis had been made.
Details of the patients are given in Table I. The freshly-harvested surgical specimens
were used for primary culture. Also, in three patients, bone graft was taken during the
operation and some of this tissue was used for the study.
Informed consent from the patients and ethical approval had been obtained for the study.
Cell isolation. The tumour or normal bone tissue was placed in nutritional medium
(RPMI- 1640; GIBCO, Carlsbad, California) containing antibiotics (100 U/ml of
penicillin and 100 µg/ml of streptomycin; Sigma, St Louis, Missouri) and transferred to
the cellculture laboratory in the Pasteur Institute of Iran. The tissues were rinsed in
phosphate-buffered saline (PBS) (Sigma), transferred to a Petri dish and cut into small
pieces < 1 mm in size. These were incubated with 1% collagenase type III (Sigma)
diluted in complete medium (RPMI + 10% fetal bovine serum) for five hours at 37° C in
a humidified atmosphere with 5% CO2. Tumour cells and osteoblastic cells from normal
bone were cultured in complete medium at 37°C and 5% CO2. The culture medium was
renewed twice a week. After four to five passages, the giant cells and monocytes had
disappeared from the culture and stromal GCT cells were almost the only remaining cells.
A homogenous tumour-cell population was collected for the study after the ninth to 12th
passages. Osteoblasts from normal bone were obtained after two or three passages.
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Table I. Details of the five patients and location of the giant-cell tumour
Immunofluorescent labelling. For immunofluorescence studies, tumour cells from

different passages were placed on chamber slides. In the early passages, the fluorescence
labelling was performed with anti-CD68 (DAKO, Hamburg, Germany) known as a
specific antigen for osteoclast-like giant cells. In later passages, fluorescence labelling
with anti-Osteonectin (Zymed, Los Angeles, California) was used to differentiate stromal
GCT cells from fibroblasts. The fluorescein isothiocyanate-labelled secondary rabbit anti-
mouse antibody (Dako Deutschland GmBH, Hamburg, Germany) was diluted 1:20. Each
antibody was incubated for one hour at 37°C. Emission of fluorescein isothiocyanate was
at a wavelength of 495 nm.
Preparation of cement cylinders containing antiblastic drugs. Cylinders of cement were
prepared using Simplex P bone cement (Howmedica, Mahwah, New Jersey) which
consists of 40 g of PMMA powder including 4 g of barium sulphate and 20 ml of solvent
(2.6% of polymerisation accelerator N, N-dimethyl-p-toluidine and 97.4% of
methylmethacrylate monomer) with the addition of an antiblastic drug powder containing
amethopterin, doxorubicin hydrochloride and cisplatin platinum (II) diammine dichloride
(Sigma). The cylinders were 3 mm in diameter, 4 mm in height and weighed 60 mg.
Cylinders either contained no added drugs or had four different doses of each drug as
follows: 75 µg, 100 µg, 150 µg and 240 µg. We had initially performed a pilot study in
which we compared the details of the cylinders to establish their homogeneity and also
their equal ability to elute cytotoxic drugs at each concentration. The cylinders were
sterilised by gamma radiation and all the tests were carried out 24 hours after their
manufacture in order to avoid the adverse effect of heat polymerisation of the cement and
to prevent its interference with the effect of the eluted drugs on our results.
Cytotoxic assay. In order to test the cytotoxic effect of the drugs which were eluted from
the cement, each cylinder was placed in a 96-well plate (Nunc, Roskilde, Denmark). The
cylinders containing different concentrations of methotrexate, doxorubicin and cisplatin
were placed in the plate in the order shown in Figure 1a. The control wells contained
cylinders without either drug or media. For the comparison between the cytotoxic effect
of drugs on tumour tissue and bone in the three patients who had a bone graft, only one
dose ( 100 µg) of antiblastic drugs was used. Similarly, another plate (Fig. 1b) with the
same design and including only stromal GCT cells and osteoblasts was prepared for each
patient. In each well, 2 x 10^sup 3^ cells were seeded. The study was repeated three
times. For each patient and each time interval two plates (one with cement cylinders and
one with cells) were prepared. All the plates were incubated at 37°C in an atmosphere of
5% CO2. A total of 100 µl was collected from each well and added to the corresponding
well on the cell plate at days 3, 7 and 14 of the experiment. After incubation for two days,
we assessed the proliferation of stromal GCT cells in the presence of eluted cytotoxic
drugs using dimethylthiazol diphenyl tetrazolium bromide (MTT). The media were
removed from the wells and replaced with 100 µl of a 0.5 mg/ml solution of MTT
(Sigma) dissolved in PBS for five hours at 37°C. The formazan crystals formed were then
dissolved by the addition of 100 µl of isopropanol (Sigma) per well. The plates were
incubated at 37°C for ten minutes. The optical density was recorded on a multiwell
microplate reader (ICN, Basel, Switzerland) at 570 nm.
Measurement of the elution of antiblastic drugs from the cement cylinders. Cement
cylinders with the same characteristics (four different concentrations of the three drugs)
were prepared for the release assay and placed in a 96-well plate filled with 100 µl of
media. The control wells contained cement cylinders without either drugs or media. The
plate was incubated at 37°C in 5% CO2 atmosphere. The concentrations of eluted drugs
were measured every two days for one month using spectrophotometry (Amersham,
Piscataway, New Jersey) at 303 nm for methotrexate, 252 nm for doxorubicin and 300
nm for cisplatin. For each measurement the media were removed from each well and
replaced with 100 µl of fresh media. The assay was repeated three times.
Statistical analysis. Group differences were assessed using General Linear Models
(GLM), adjusting for potential confounders. When these test results were significant, the
Tukey multiple-comparison test was performed. A p-value ≤ 0.05 was considered to be
statistically significant.
Results
The characterisation of stromal GCT cells. The immunofluorescent study showed that
plates containing stromal GCT cells, were positive for anti-Osteonectin labelling and that
the control group of fibroblast cells was negative. Also, in the early stages, the GCT
specimens were positive for anti-CD68.
Elution of cytotoxic drugs. The release of each drug in different concentrations is shown
in Figure 2. At one month the release of all three drugs had almost the same pattern. It
was greatest on the first day and decreased dramatically after the third day with a
permanent rate of elution being achieved after one week. The eluted drugs correlated with
the amount incorporated into the cylinders but this difference decreased with the passage
of time and became negligible at the end of the experiment. In addition, the pattern of
release remained similar for all four doses of each drug.
T a
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Figure 1a - diagram of a 96-well cement plate with methotrexate (MTX), doxorubicin (DOX)
and cisplatin (CIS) in different concentrations (1, 240 µg; 2, 150 µg; 3, 100 µg; and 4, 75µg) in
the presence of complete Roswell Park Memorial Institute 1640 media. For the comparison
assay between stromal giant-cell tumour cells and bone used, the same cylinders, abbreviated as
MTXB, DOXB, and CISB with only one dose (100 µg), were used. Wells represented as
CEMENT contained cylinders with no drug. Unmarked wells had only media. The x marked
wells contained phosphate buffered saline for inhibiting the edge effect. Figure 1b - diagram of a
96-well plate with giant-cell tumour stromal cells (GCTSC) and osteoblasts. A total number of 2
x 10^sup 3^ cells was seeded in each well. At different time intervals the supernatant from each
well of the cement plate (Fig. 1a) was added to the cell plate. The x marked wells contained
phosphate buffered saline for inhibiting the edge effect.
The amount of drugs eluted for each of the four doses is shown in Table II. The
proportion of the amount eluted to the amount incorporated in the cylinders was smallest
for the highest concentration (240 µg) and greatest for the lowest concentration (75 µg)
except for the methotrexate during the first week, in which the four concentrations had
practically the same amount of elution. The mean percentage of drug eluted in the first
week was 6.3% for methotrexate, 6.0% for doxorubicin and 6.1% for cisplatin, and at
four weeks was 9.3% for methotrexate, 11.0% for doxorubicin and 7.6% for cisplatin.
The effect of eluted cytotoxic drugs on stromal GCT cells. In Figure 3 the cytotoxic
effect of the drugs on stromal GCT cells in each patient is shown separately. After
adjustment for time, there was no significant difference between the two control groups,
cells only and cylinders without drugs, (F = 0.16, p = 0.692). Thus the cement was not
cytotoxic and did not affect cell survival.
In multivariate analysis, the drug (F = 4.5, p = 0.01), day (F = 5.7, p = 0.001 ) and dose
(F = 105, p < 0.001) were significant predictors of cytotoxicity. The day of assessment
was a significant predictor of cell survival after adjustment for the dose of each drug (p <
0.001 in all analyses).
G
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Graphs showing the release pattern of the cytotoxic cylinders over one month for a)
methotrexate (MTX), b) doxorubicin (DOX) and c) cisplatin (CIS) measured at a specific optical
density of 303,252 and 300 nm, respectively. Four concentrations were used for each drug (1,
240 µg; 2, 150 µg; 3, 100 µg; and 4, 75 µg).
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Table II. The amount of drugs eluted from the cement cylinders for the four different doses after
one and four weeks (the eluted percentage of drug incorporated in the cylinders is given in
parentheses)
The effect of the drugs on cell survival is shown in Table III. Although there were no
clear differences between the four doses of each drug at day three, cell survival with
different doses of drugs began to change at day seven (Fig. 3) and at day 14 there were
clear differences between the four doses of each drug. There were no significant
differences between the four doses of each drug in the whole experiment after adjustment
for day. With increasing time, as the cells proliferated, the therapeutic action of the drugs
decreased, but even at the lowest dose of each drug at day 14, there was a considerable
cytotoxic effect on stromal GCT cells (45% for doxorubicin, 34% for cisplatin and 31%
for methotrexate). Of the three drugs, doxorubicin was clearly the most potent, after
adjustment for dose, but this difference was statistically significant only on day seven (F
= 12.2, p < 0.001). There was no visible or significant difference between methotrexate
and cisplatin.
G
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Histograms showing the cytotoxic effect of eluted antiblastic drugs on stromal giant-cell tumours
(GCT) cells demonstrated by dimethylthiaeol diphenyl tetrazolium bromide assay. The result of
cell viability of eluted a) methotrexate (MTX), b) doxorubicin (DOX) and c) cisplatin (CIS), for
each patient at day (D) 3, day 7, and day 14 is represented at an optical density of 540 nm. Four
different concentrations were used for each drug (1, 240 µg; 2,150 µg; 3, 100 µg; and 4, 75 µg).
In addition, the control groups including cement with no drugs (GCT+cement) and cells only
(GCT) are shown.
In post hoc analyses (Tukey), doxorubicin was significantly more effective (p = 0.05)
than the others, with the 240 µg dose being significantly more effective (p = 0.05) than
the third-placed 100 µg or fourth-placed 75 µg doses. Additionally there were significant
differences between the cytotoxic effects of each drug at each concentration on days 3, 7
and 14.
Comparison of the effects of eluted drugs on stromal GCT cells and osteoblasts. A
comparison between the effect of eluted drugs on both tissues was made using one dose
of each drug (100 µg). The result of cell survival is shown in Table IV. On days 3 and 7,
there were no differences between the effects of the drugs on both tissues. These
differences became more apparent on day 14, when all the drugs seemed to have a more
cytotoxic effect on bone cells. Doxorubicin was the most potent drug for bone tissue also,
and there was no significant difference between methotrexate and cisplatin. In
multivariate analysis using the general linear model, stromal GCT cells or osteoblasts
were not significant predictors of cytotoxicity.
Discussion
Recurrence rates of between 0% and 25% have been reported after the treatment of GCTs
by curettage and packing with PMMA.1,3,16 In order to reduce the local recurrence rate
various associated local adjuvant treatments such as phenol, alcohol and
polymethylmethacrylate, have been proposed.1 We have examined the effect of eluted
methotrexate, doxorubicin and cisplatin from PMMA on the primary culture of GCT
cells. The drugs which were chosen are commonly used in the treatment of bone sarcoma,
and have been shown to have specific effects on stromal GCT cells, which are thought to
be the neoplastic component of the tumour. Some investigators, have mixed cement with
cytotoxic drugs and used the combination to reduce the local rate of recurrence of the
tumour. Hernigou et al,13 reported a considerable local concentration of eluted
methotrexate from the cement in the treatment of malignant tumours. Greco etal,12
reported similar findings using doxorubicin and cisplatin, and Kirchen et al17 described a
chemotherapeutic effect of eluted methotrexate on two GCT cell lines.
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Table III. Percentage of cell survival of eluted antiblastic drugs (methotrexate, doxorubicin, and
cisplatin) on giant-celt tumours of stromal cells in four different concentrations (µg) at three
intervals
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Table IV. Comparison of the cell survival (%) of methotrexate, doxorubicin and cisplatin on
giant-cell tumour stromal cells (GCTSC) and osteoblasts. Only one dose (100 µg) was used
We found a significant difference between the cytotoxic effects of eluted drugs on

different days of the study. On day 3, the cytotoxic effect was nearly the same for all four
doses of the drug. By day 7 the differences between the four doses had become more
apparent and on day 14 they were clear, with 240 µg doses significantly more effective
than of doses of 100 µg or 75 µg. As expected, doxorubicin was the most potent drug, but
there was no significant difference between methotrexate and cisplatin. The therapeutic
effect of the three drugs and the differences between them decreased towards the end of
the experiment.
Rosa et al18 have shown that the cell inhibition induced by cytotoxic drugs eluted from
cement was the same after 15 days. The reduced cytotoxic effect in our study could be
due either to cell proliferation or to the reduction in the amount of the eluted drugs. We
did not examine these two factors separately, but the lowest dose of each drug still had a
considerable cytotoxic effect on the last day of the experiment: 45% for doxorubicin,
34% for cisplatin and 31% for methotrexate.
In three patients, a comparison of the cytotoxic effect of the drugs was made between
intact bone and stromal GCT cells collected from the same patients. There was no
significant difference in the behaviour of the two tissues towards the drugs. However, a
slight difference in the growth of the two tissues was detected after 14 days.
The elution of drugs from PMMA remains controversial. Most studies have been
performed with antibiotics, and suggest that the formulation19 and microstructure of the
cement, and the amount20 and combination21 of the drugs incorporated in the cement
could influence the rate of elution. For cytotoxic agents, fewer factors have been studied.
As for antibiotics, the formulation of the cement affects the elution22 and, as far as drug
combination is concerned, a mixture of pamidronate and doxorubicin rather than each
drug separately and showed a better rate in the combination form.20 The surface of the
cement may also affect elution.17 Different amounts of elution have been reported.
Wasserlauf et al,22 showed elution of up to 6% for methotrexate, 3.3% for cisplatin and
3.4% for 5-fluorouracil. Kim et al23 noted a mean elution of methotrexate of 6.1% in the
first week and a total of 9.6% for a period of four weeks. Handal et al24 suggested a
method of predicting the amount of the drug released from cement.
In our study, all the drugs had the same pattern of release. It was greatest during the first
day and dramatically decreased after the third. A small amount of release continued for
one month. This initial rapid release has been previously described.15,25 There was a
direct relationship between the eluted drugs and the amount incorporated in the cement,
but this difference became less apparent towards the end of the experiment and the
amount eluted in different doses was practically the same. We found that the proportion
of drug eluted to the amount incorporated into cylinders was greatest for the lowest
concentration of each drug. This has also been observed by Maccauro et al.15 After four
weeks, doxorubicin had the highest rate of elution with a mean of 11 % compared with
9.25% for methotrexate and 7.62% for cisplatin.
According to the Developmental Therapeutics Program NCI/N1H the 50 Lethal
Concentration (LC50) of methotrexate, doxorubicin and cisplatin are, respectively, 1 x
10^sup -5^ M, 1 x 10^sup -4.6^ M and 1 x 10^sup -4.3^ M.26 In our experience, the
mean amounts of eluted in the lowest and highest doses of each were 1.8 x 10^sup -5^ M
to 4.2 x 10^sup -5^ M for methotrexate, 2 x 10^sup -5^ M to 2.8 x 10^sup -5^ M for
doxorubicin and 2.8 x 10^sup -5^ M to 3.8 x 10^sup -5^ M for cisplatin. Consequently,
the eluted drugs were practically all in the range of the mentioned LC50.
The use of adjuvant cytotoxic drugs in the treatment of a benign tumour may be
considered to subject a patient to unnecessary side-effects. A GCT, however, is a
potentially malignant lesion with a rate of local recurrence which is higher than that of
other benign tumours.1 Although curettage has been advocated for the treatment of local
recurrences,3 the size of the tumour is often underestimated, leading to incomplete
removal. Even in aggressive GCTs the adjacent joint is usually preserved and successful
local adjuvant therapy would lead to improved outcome.
Our results show that drugs from PMMA have cytotoxic effects on stromal GCT cells
and these effects are related to the concentration of the drugs incorporated into the
cement and the interval at which the effect is measured. There were no clear differences
between the cytotoxic effects of the four doses of each drug initially. This pattern
changed with time, and clear differences were detected at the end of our study, even
although there remained considerable cytotoxicity with the lowest dose of each drug.
Hence, bearing in mind the fact that low doses of cytotoxic drugs have fewer side-effects,
a relatively small dose could lower the rate of recurrence after curettage and packing with
PMMA. However, the effect of this adjuvant therapy on GCT and the surrounding bone
requires a larger study both in vitro and in vivo before it could be recommended for
clinical use. Many other factors such as the blood supply, the site of the tumour, and the
kinetic characteristics of drug release from cement could potentially influence the in vivo
model and should be considered in further studies.
We wish to thank the following: Dr G. Ghorbani for helping to collect the patient
samples, Dr H. Tafreshi for his valuable advice on the cytotoxic assay, Dr R. Yusefi-
Mooraie for his role in the statistical analysis, Dr R Sadeghipour for his helpful
comments in the preparation of the cement cylinders and Mr. A. Azizmohamadi for his
English editing.
This work was supported by grants from Medical Science/University of Tehran and
Pasteur Institute of Iran.
No benefits in any form have been received or will be received from a commercial party
related directly or indirectly to the subject of this article.
[Reference] » View reference page with links
References
1. Szendröi M. Giant-cell tumor of bone. J Bone Joint Surg [Br] 2004;B:5-12.
2. Wuelling M, Engels C, Jesse N, et al. Histogenesis of giant cell tumors. Pathologe 2002;
23:332-9.
3. Turcotte RE. Giant cell tumor of bone. Orthop Clin North Am 2006;37:35-51.
4. Wada T, Kaya M, Nagoya S, et al. Complications associated with bone cementing for the
treatment of giant cell tumors of bone. J Orthop Sci 2002;7:194-8.
5. Webb JL, Spener RF. The role of polymethylmethacrylate bone cement in modern
orthopaedic surgery. J Bone Joint Surg [Br] 2007;89-B:851-7.
6. Bucholz HW, Eneelbrecht E. Uber die depotwirkung einiger antibiotika bei verminschung mit
dem kunstharz palaces. Chirug 1970;41;511-13 (in German).
7. Marks KE, Nelson CU Lautenschlager FP. Antibiotic-impregnated acrylic bane cement. J
Bone Joint Surg [Am] 1976;58-A:358-9.
8. Josefsson G, Lindberg L, Wiklander B. Systemic antibiotics and gentamicin containing bone
cement in the prophylaxis of post-operative infections in total hip arthroplasty. Clin Orthop
1981;159:194-200.
9. Marr MA, Algozzine GJ. Use of bone cement containing tobramicin sulphate. Clin Pharm
1983;2:1B:401.
10. Desto CM, Hart LL. Antibiotics in acrylic. Drug Intell Clin Pharm 1984;18:883-4.
11. Jain AK, Panchagnula R. Skeletal drug delivery systems. Int J Pharm 2000;206:1-12.
12. Greco F, De Palma L. Specchia N, Jacobelli S, Gaggini C. Polymethylmethacrylate-
antiblastic drug compounds: an in vitro study assessing the cytotoxic effect in cancer cell lines- a
new method for local chemotherapy of bone metastasis. Orthopedics 1992;15:189-94.
13. Hernigou P, Thiéry JP, Benoit J, et al. Methotrexate diffusion from acrylic cement: local
chemotherapy for bone tumors. J Bone Joint Surg [Br] 19B9;71-B:804-11.
14. Wang HM, Galasko CS, Crank S, Oliver G. Ward CA. Methotrexate loaded acrylic cement
in the management of skeletal metastases; biomechanical, biological, and systemic effect. Clin
Orthop 1995;312:173-86.
15. Maccauro G, Cittadini A, Casarci M, et al, Methotrexate-added acrylic cement: biological
and physical properties. J Mater Sci Water Med 2007;18:839-44.
16. Vult von Steyern F, Bauer HC, Trovik C, et al. Treatment of local recurrences of giant cell
tumour in long bones after curettage and cementing: a Scandinavian Sarcoma Group study. J
Bone Joint Surg [Br] 2006;88-B:531-5.
17. Kirchen ME, Menendez LR, Lee JH, Marshall GJ. Methotrexate eluted from bone cement:
effect on giant cell tumor of bone in vitro. Clin Orthop 1996;328:294-303.
18. Rosa MA, Maccauro G, Sgambato A, et al. Acrylic cement added with antiblastics in the
treatment of bone metastases: ultrastructural and in vitro analysis. J Bone Joint Surg [Br]
2003;85-B:712-16.
19. Elson RA, Jephcott AE, McGechie DB, Verettas D. Antibiotic-loaded acrylic cement. J Bone
Joint Surg [Br] 1977;59-B:200-5.
20. Healey JH, Shannon F, Boland P, DiResta G. PMMA to stabilize bone and deliver
antineoplastic and antiresorptive agents. Clin Orthop 2003;415:263-75.
21. Penner MJ, Duncan CP, Masri BA. The in vitro elution characteristics of antibiotic-loaded
CMW and Palacos-R bone cements. J Arthroplasty 1999;14:209-14.
22. Wasserlauf S, Warshawsky A, Arad-Yelin R, at al. The release of cytotoxic drugs from
acrylic bone cement. Bull Hosp Jt Dis 1993;53:68-74.
23. Kim HS, Park YB, Oh JH, Yoo KH, Lee SH. The cytotoxic effect of methotrexate loaded
bone cement on osteosarcoma cell lines. Int Orthop 2001;25:343-8.
24. Handal JA, Frisch RF, Weaver WL, Williams EA, Dimatteo D. Method for the physical
analysis of drug-bone cement composite. Clin Orthop 2007;459:105-9.
25. Yan X, Gemeinhart RA. Cisplatin delivery from poly(acrylic acid-co-methyl methacrylate)
microparticles. J Control Release 2005; 106:198-208.
26. No authors listed. Developmental Therapeutics Program NCI/NIH. www.dtp.nci.nih.gov
(date last accessed 4 September 2007)
27. McGough RL, Rutledge J. Lewis VO. Lin PP, Yasko AW. Impact severity of local
recurrence in giant cell tumor of bone. Clin Orthop 2005;438:116-22.
Bisphosphonates reduce local recurrence in extremity giant cell tumor of bone: A case–
control study
This article is not included in your organization's subscription. However, you may be able
to access this article under your organization's agreement with Elsevier.
Lung Fung Tsea, , , Kwok Chuen Wonga, Shekhar Madhukar Kumtaa, Lin Huangb,
Tsun Cheung Chowc and James Francis Griffithd
Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Shatin, Hong
a
Kong
b Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong
Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, Shatin,
c
Hong Kong
dDepartment of Diagnostic and Interventional Radiology, Prince of Wales Hospital,
Shatin, Hong Kong
Received 21 May 2007;
revised 19 July 2007;
accepted 21 August 2007.
Available online 6 September 2007.
Abstract
Background:
Giant cell tumor (GCT) of bone is a benign but locally aggressive tumor that is
characterized by the presence of mononuclear stromal cells and multinucleated giant
cells. Although topical adjuvants have been used in the past, local recurrence following
intralesional excision of GCT of bone continues to remain a problem. The use of
bisphosphonates as an anti-osteoclastic agent in the management of osteolytic bone
metastases is well accepted. Furthermore in vitro studies have shown that
bisphosphonates also induce apoptosis in GCT stromal cells. Therefore our clinical study
aims to investigate whether the administration of bisphosphonate as an adjuvant can
further decrease local recurrence following the surgical treatment of GCT of bone.
Method:
A retrospective case–control study was performed between 1988 and 2004. Forty-four
patients with histological diagnosed appendicular GCT were included. Intralesional
curettage or wide excision of the lesions was followed with cementation or biological
reconstruction. Additional intravenous and oral bisphosphonates were given peri-
operatively to 24 patients who were treated between 1998 and 2004. The average follow-
up of the control group was 115 months while that of the treatment group was 48 months.
Results:
In the bisphosphonate treated group, 1 of 24 patients (4.2%) developed local recurrence.
In the control group, 6 of 20 patients (30%) developed local recurrence. The difference in
the recurrence rate was statistically significant between the bisphosphonate treatment
group and the control group (Log Rank test p = 0.056). The effect of reduction of local
recurrence was significant in patients with stage III diseases. Patients treated with
bisphosphonate did not report any untoward effects.
Conclusion:
Clinical use of bisphosphonates as an adjuvant therapy for giant cell tumor of bone
demonstrated a lower local recurrence rate. The clinical response seems to be more
promising in stage III diseases.
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Int Orthop. 2009 Feb;33(1):203-9. Epub 2007 Aug 28.
Functional outcome following excision of

a tumour and reconstruction of the distal
radius.
Asavamongkolkul A, Waikakul S, Phimolsarnti R, Kiatisevi P.
Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, 10700, Thailand. siaas@mahidol.ac.th
Abstract
We retrospectively studied the functional and oncological results of 15 patients after
reconstruction of the distal radius with osteoarticular allograft or non-vascularised fibular
graft following wide excision of an aggressive benign or malignant tumour. Eight
patients underwent osteoarticular allograft and seven patients had a non-vascularised
autogenous fibular graft reconstruction. The average time for incorporation of the graft
was 6 and 5 months in each reconstruction respectively. There was no tumour recurrence
after follow up over 41.5-95.5 (average 60.5) months. All patients had good and excellent
functional results. Three patients in the group reconstructed with osteoarticular allograft
had plate loosening and graft fractures which were successfully treated subsequently.
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Zhonghua Wai Ke Za Zhi. 2006 Dec 15;44(24):1693-8.
[The choice strategy of surgical treatment

for giant cell tumor close to the knee]
[Article in Chinese]
Yang ZM, Tao HM, Yang DS, Ye ZM, Li WX.
Department of Orthopaedics, the Second Affiliated Hospital, Institute of Orthopaedic
Research, Medical College Zhejiang University, Hangzhou 310009, China.
Abstract
OBJECTIVE: To retrospectively study and analyze the methods of the surgery
management for giant cell tumor close to the knee. METHODS: A retrospective analysis
was performed in 121 patients who underwent surgical treatment for giant cell tumor
close to the knee between 1978 and 1997. There were 71 cases had been managed with
an intralesional procedure of the tumor (curettage, freezing with liquid nitrogen and
autograft or allograft, Group 1), 50 cases with a semi-arthroplasty using allograft after en
bloc resection (Group 2). According to the relation of the clinical signs and symptoms,
tumor character, operative method and local recurrence, limp function, complication were
evaluated. Based on the figure of tumor lesion on CT, a new formulation of treatment
was given: (1) I diameter of tumor <or= 1/2, choice of an intralesional procedure; (2) II
1/2 approximately 3/4, an intralesional procedure additional inter fixed; (3) III > 3/4, en
bloc resection and reconstruction. The prospectively collected records of 65 cases of
patients, 45 cases with curettage, heat cauterization with electrocautery and phenol,
autograft and cement (Group 1), 20 cases with arthroplasty using prosthetic (Group 2),
who had a giant-cell tumor closed knee, were reviewed to determine feasibility of the
new formulation of treatment. RESULTS: The first duration, the rate of the local
recurrence between 2 groups showed no statistical difference. There were less
complication rate and better limp function after using two different surgical treatment.
The second duration, there were no statistical difference with the rate of the local
recurrence, complication, and limp function. The number of patients who managed with
en bloc resection and reconstruction decreased. CONCLUSIONS: The choice strategy of
surgical treatment for giant cell tumor close to the knee should be based on the figure of
tumor lesion on CT. It gives a new formulation of treatment to choice of an intralesional
procedure and en bloc resection. An effective intralesional procedure should be the
method of the first choice.
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Zhonghua Wai Ke Za Zhi. 2006 Jun 15;44(12):797-800.
[Analysis of the factors affecting the

recurrence of giant cell tumor of bone]
[Article in Chinese]
Guo QC, Shen JN, Wang J, Huang G, Zou CY, Jin S, Yin JQ, Liao WM.
Department of Orthopedics, the First Affiliated Hospital of Sun Yat-sen University,
Guangzhou 510080, China.
Abstract
OBJECTIVE: To analyze the clinical factors affecting the recurrence of giant cell tumors
(GCT) of bone. METHODS: The complete data of 146 cases with GCT were reviewed.
Thirteen clinical factors were analyzed by chi(2) analysis. And the related Campanacci's
grade system and Jaffe's grade system was analyzed by Crosstabs analysis. Multipal
factors were analyzed by Logistic regression analysis. RESULTS: Nineteen of 146 cases
recurred, and recurrence rate was 13.0%. Recurrence rates of curettage and enblock
resection groups were 18.8% and 6.3% respectively. And recurrence rates of curettage
with or without of extensive procedure were 12.9% and 38.9%. Five cases had lung
metastasis, and two cases presented with malignant transformation. The metastasis rate
and the rate of malignant transformation were 3.4% and 1.4% respectively. The two
factors of surgery method and burst out of bone-envelope appearance were related with
the recurrence. Moreover, Logistic regression revealed that the surgery method
significantly affected the recurrence. And Campanacci's grade system and Jaffe's grade
system were not related to each other. CONCLUSIONS: Surgery method is the main
factor affected the recurrence of GCT, and Campanacci's grade system or Jaffe's grade
system has no prognostic value.

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Long bones giant cells tumors: Treatment by curretage and cavity filling cementation

N. Fraqueta, G. Faizonb, P. Rossetb, J.-M. Phillipeaua, c, D. Waasta and F. Gouina, , c,

Nantes cedex, France

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Figure 1. Preoperative X-ray.

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Figure 2. Intraoperative view after curettage. Mechanical reaming as a complement to

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Figure 3. X-ray at 4 years of follow-up. No sign of osteoarthritis, no scalable border.

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Figure 4. A. Window for curettage cementation. B. The subchondral bone fractures. C.

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[1] Babinet A. Tumeur à cellule géantes : cahier d’enseignement de la Sofcot. Elsevier

[7] F. Vult Von Steyern, I. Kristiansson, K. Jonsson, P. Mannfolk, D. Heinegård and A.

[9] J. Vidal, R. Mimran and Y. Allieu, Plastie de comblement par méthacrylate de

Correspondence should be sent to Dr A. Puri; e-mail: docpuri@vsnl.com

Fig. 1a, Fig. 1b Pre-operative anteroposterior a) and lateral radiographs b)

Fig. 2a, Fig. 2b Anteroposterior a) and lateral radiographs b) 12 months

Fig. 3 Photographs showing forearm rotation after ulnar

Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J

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